Induction of specific immunologic tolerance is an ultimate goal of organ transplantation. Based on the conditioning regimen developed in our laboratory by decades-long research in nonhuman primates (NHP), we have now successfully achieved renal allograft tolerance in HLA mismatched human kidney transplant recipients via the mixed chimerism approach. However, limitations of this approach have been its inapplicability for deceased donor transplantation and the inability to induce tolerance of non-renal organs/cells. To extend this approach to deceased donor transplantation, we recently developed a novel strategy of delayed tolerance induction, where kidney transplantation is performed first with conventional immunosuppression, followed by conditioning and donor bone marrow transplantation at a later date. In our preliminary NHP investigations, several barriers to consistent tolerance induction with this novel approach have been identified including higher alloreactive memory T cells (Tmem) and inflammatory responses. In order to develop a consistently reliable conditioning regimen for clinical application to deceased donor kidney recipients, it is essential to identify additional modalities to effectively mitigate inflammatory and Tmem responses without increasing morbidity in the recipients. Aims 1 and 2 of this project are, therefore, designed to evaluate novel anti-inflammatory agents (anti-IL6R mAb and alpha1 antitrypsin) and strategies to overcome Tmem responses (costimulatory blockade and B cell depletion). This Project's goals also include extension of the applicability of our approach to organ/cell transplantation other than the kidney. This appears to be possible via the novel strategy of co-transplantation of the kidney with less tolerogenic organs/cells. Our studies have shown that the kidney allograft plays a critical role for induction and maintenance of tolerance of the co-transplanted organ/cells. Aim 3 of the current study is thus designed to induce islet allograft tolerance by co-transplantation of islets and the kidney. While Project 2 will pursue islets allograft tolerance in living donor transplantation. Project 1 will develop the strategy to induce islet allograft tolerance in deceased donor transplantation. Since islets are especially susceptible to inflammatory and Tmem responses, we will incorporate novel modalities to be identified in Aims 1 and 2 into the conditioning regimen for induction of islet allograft tolerance. Finally, mechanisms by which (transient) mixed chimerism and the renal allograft induce islet allograft tolerance, will be fully investigated in collaboration with Project 3.